Treatment of altered passive eruption with socket shield

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Posted on By Howard Gluckman In Implants

This workflow shows the digital treatment planning and workflow together with a guided stent allowing the predictable removal of the correct soft tissue and bone. This is all planned on CBCT with the understanding of how much gingiva can be removed without exposing the CEJ and the root. The patient also required an implant in the #7 due to a fracture as a result of trauma. This was her initial reason for seeking treatment. the fracture was horizontal and just above the gum line. The video describes the worlflow and hopefully will help in the diagnosis and treatment of this type of case.


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I'm always impressed my your presentations and this case is not an exception.
However, I'm little concerned with this case.The patient has significant wear which I suspect has contributed to the demise of the central.
The anterior bruxism my indicate a sleep disorder/occlusal issues or other underlying problem.
My questions are -would you undertake any further investigations prior to implant placement, would you not be reluctant to place any restoration (provisional or permanent) in such a case and how would you be confident about preventing further teeth damage around the implant and potentially the implant itself.
I say this with the concern that simply placing a splint as a night guard could worsen the underlying sleep disorder if present
Thanks again -great case and I know you'll give the perfect answer


Thanks for the comments Barry. You are absolutely right and we have completed the planning for this case with DSD which has higlited the need for management of her anterior wear. She will have treatment of the 4 anterior teeth. That being said there are many cases I have dine which no doubt need a more integrated approach but the patients are simply not interested or do not have the financial means to do more. The implants themselves have still gone onto have medium and long term success. So do we need to treat every case as ideal as possible absolutely is it always possible I don't find that. What are your thoughts


I agree Its always difficult when a patient can't have or doesn't want all the treatment prescribed. Its challenging to then decide how to treat best within the restricted parameters the patient sets. Also the medico-legal question (especially in UK) is often "how much of a compromise in treatment am I prepared to accept " before the legal experts suggest that if the patient did not want all the prescribed treatment then "why did you place an implant when you knew the treatment outcome would be compromised? These are questions we are all dealing with. My critiques in this case are more directed on should we have dealt with any occlusal concerns/sleep disorder/habits etc prior to placing an implant as failure to do so potentially compromises not just the implant but all the dentition. The case has been carried out beautifully, and your skills are obvious. However, given the cost of the implant treatment I feel I would have tried to diagnose any underlying problems to reduce treatment failure and further dental issues prior to embarking on implant treatment or at least be carrying this out coincidentally with treatment. I also fail to understand how DSD treatment on the 4 anteriors will alter underlying concerns. I sincerely value your expertise and skills and mean no malice. I would appreciate your views on the possible cause of anterior attrition in this case Many thanks


Barry Im curious to understand what sleep disorder she has and the second question is if she has no symptoms of MPDS what occlusal issue are we trying to treat for her. Occlusal wear is certainly there and discussed and dealt with but if a patient does not want to have a full recon is that considered bad treatment and should we be criticising others because the patient does not want to go through that. I would challenge any expert to challenge that aspect of treatment. Secondly will it affect my treatment of the front teeth I don't think so at all.
With regards your question about DSD I think it speaks for itself. Digital planning of a gummy smile is essential in my books as is planning of the position of the implant if one is going to close the gaps between the front teeth. I appreciate your comments thanks for the interaction


Hi Howard
Current research is demonstrating a high proportion(up to 80%) of night time bruixists have an underlying sleep disorder. This is especially true for anterior wear cases. Jeff Rouse teaches this in his seminars as well as several others. Putting in a simple night guard for these patients could well be detrimental to their health as in can worsen the sleep disorder.
Whilst the patient has no symptoms of MFDS she certainly has classic signs of ongoing wear and whilst trauma would have been the significant factor I wonder if the teeth have been previously weakened to enhance any exterior forces.
The DSD planning is fantastic and this case demonstrates how proficient it is at producing a fabulous aesthetic result. I assume you believe is that due to wear of the incisal edges of the anteriors there has been passive eruption contributing to the gummy smile. And that's my point, if this wear is current and ongoing further damage to the teeth is inevitable no matter how beautiful your skills and DSD planning are to restore the 4 front teeth.
Also the canines appear to be significantly worn and may need attention
My concern is that this has cost the patient a lot of time, effort, and financial investment. I would like to give in the best chance of surviving.
I have no intention of being negative or critical. I have met you on courses and referred patients to you. I value your skills and knowledge. It's just in this case I felt uncomfortable with the apparent rush to place an implant/pet technique and undertake DSD treatment when the possible ongoing anterior wear and subsequent damage to the adjacent dentition had seemingly not been diagnosed and treated as you felt appropriate.


Masterful. Very important to perform the crown length and esthetic plan BEFORE implant positioning and placement. Most would not consider that. Great job. Mo